2001 Conference Proceedings

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Bob Segalman, Ph.D., Research Analyst
Program Evaluation and Statistics Section
California Department of Rehabilitation
3330 Tropicana Court
Sacramento, CA 95826
phone 1-800-854-7784 and ask for me at 916-362-0982
E-mail: drsts@comcast.net


People with speech disabilities in fifteen states can now use a special telephone service provided for them. This service, called Speech-to-Speech (STS), grew out of my own attempts to be understood over the telephone despite my cerebral palsied speech. Speech-to-Speech provides human voicers for both voice synthesizer users and people with moderate speech disabilities who have difficulty being understood by telephone.

The Federal Communications Commission requires that Speech-to-Speech be provided nationwide by March 2001. Speech-to-Speech is now offered in the following fourteen states 24 hours a day: California, Arizona, Illinois, Wisconsin, Washington, Nevada, Texas, North Carolina, South Carolina, South Dakota, Maryland, Minnesota, Georgia, Kentucky and Utah. Sweden is conducting national trials, and Australia has begun permanent service.

People with speech disabilities call a toll free number to use STS. STS can extend telephone service to many people with speech disabilities who cannot use regular telephone service or the TTY Relay Service.

Users now access STS through the vendor who provides the TTY relay. The TTY relay itself is only accessible for calls between a TTY user and a voice user. Communications assistants (who previously only translated TTY output to voice and vice-versa) now repeat the words of the person with the speech disability or synthesizer output to the listener.

While STS can use technology analogous to three-way calling technology, it provides a human interface that three-way calling does not. STS is different in that three-way calling requires users to provide their own human voicers. Providing 3-way calling alone is not sufficient as only very rich people can have voicers available around the clock in the way that CRS communications assistants are available.


All STS users have speech which the general public often has difficulty understanding. These users may also have dyslexia or limited hand use (from cerebral palsy, head injury, degenerative conditions or strokes) which precludes keyboarding adequate to use a TTY relay service. The largest proportion of STS users are probably adolescents and adults with cerebral palsy or similar developmental disabilities.

Most STS users can be understood by patient listeners with acute hearing who have had a few hours of experience listening to people with such speech disabilities. STS cannot assist people whose speech is so idiosyncratic that it is only understandable by those who know them well.

Some people communicate on STS with a speech synthesizer or an artificial larynx. They require voicing services to facilitate communication similar to other users. Speech synthesizer and artificial larynx users also require communication assistants to be patient, experienced listeners who keep the able-bodied user's attention and facilitate turn-taking in communications. Many speech synthesizer and artificial larynx users find that STS compensates for e the general public being unprepared for the unusual sound of their devices or the turn-taking required for communication.

Providing telephone access to all such people broadens the historic contribution of relay service. Direct and speedy telephone access helps mainstream these people into jobs and many other activities. Such service expansion reflects the spirit of the Americans with Disabilities Act (ADA). The ADA advocates expanded applications of new technology to benefit people with various disabilities.

There is no central source for locating STS users. They must be identified one-by-one and their fears must be resolved before they were willing to use STS.

For a state to successfully build a STS user constituency, an intense outreach effort is necessary. In California two of us, both professional counselors, spent 18 months canvassing the state using an outreach model based on the social work "case finding" technique.

We called and wrote agencies and mailed thousands of flyers. We focused on secondary providers who served this population to identify potential users. Many users were recruited through their Department of Rehabilitation counselor. Other recruitment sources included: 1) Speech pathologist members of the California chapter of the American Speech and Hearing Association and the United States Society for Augmentative and Alternative Communication, 2) Regional Centers in California serving clients with speech disabilities, 3) Distributors of speech synthesizers sold in California, 4) local Alliance for Technology agencies in California, 5) United Cerebral Palsy of California and 6) Independent Living Centers.

Our screening process identified appropriate STS users. This screening assured that users have the appropriate degree of speech disability. That is, 80% percent of what they said was understood by the patient screener with acute hearing. They spoke in complete sentences and had the social skills to hold a meaningful conversation.

STS is only useful to people with speech that CAs can understand most of the time. Therefore, we do not recruit people who are not understood most of the time. Screening also insures that users have sufficient telephone knowledge and experience to use STS. Potential users also have to demonstrate enough responsibility in other aspects of life so that we could expect them to find STS useful.


The communications assistants voiced what the user with a speech disability said after every three to four word phrase. That is also the procedure that works best in face-to-face speech interpretation. We wanted the trial to utilize Cross-Hearing. That is, to maximize communication, the relay agent, the user with a speech disability, and the speech-able user must all be able to hear each other from the time the second user answers the telephone until the time one user hangs up. Unfortunately, cross-hearing was not available during the 1995 trial.

The caller understandability criteria limited the number of times that a user with a speech disability could repeat a word or phrase without agent comprehension. After two repetitions the agent would ask the caller to "say that another way" or "say something else". The former TTY communications assistants only needed a few hours of additional training prior to working as Speech-to-Speech relay agents in the trial. For the permanent program, audio tapes from the trial can be used to train additional agents. These audio-tapes can give prospective agents a "feel" for this type of relay work.

Costs included: training CA, CA's salaries, setting up work stations, use of an 800 number, and administrative costs. During the trial, 25 trial participants initiated or received 2,000 outbound telephone calls over a 4-week trial period. Some of these calls were made to trial participants by able-bodied users.

This earlier trial determined that Speech-to-Speech is readily usable on an ongoing basis by this population. It can be effectively and efficiently run as part of a TTY relay system. Based on the trial, the major changes needed for a permanent Speech-to-Speech service would be that the relay agent and both callers need to hear each other throughout the call. We also learned that CAs had to be taught how to respect callers with speech disabilities. CAs were wisely selected for the trial based on good hearing and patience. Training by someone with a speech disability was necessary. The trainer had to be available several hours a day during the trial.The 25 speech disabled users initiated over 2,000 outbound calls. Trial participants were allowed to initiate calls between 1 pm and 5 pm, Monday through Friday. The permanent system calling hours are 24 hours a day, seven days a week.

Sprint tape-recorded trial calls. Tape-recordings included what was said by: the user with a speech disability, the speech able user, and the relay agent. Users were told in advance that calls were being tape-recorded. Sprint may use such tape-recordings for agent training at a later date and permission (a signed release) was obtained from all participating parties.

Listening to a sample of those tape-recordings helped verify the system's potential to provide successful telecommunications services for this population.

The vendor provided: 1) Communications equipment and telephone lines configured to accept and process CA-relayed calls between two speaking parties 2) CAs selected and trained to relay voice communication for people with speech disabilities. These users communicated with people with unimpaired speech and with each other. I trained all CAs; 3) A system to accept, route, process and count calls; and 4) Tape-recording capability: All trial calls were taped. The relay agent's role is similar to the agent's role with TTY users, but in Speech-to-Speech a user with a speech disability replaces the TTY user. The relay agent facilitates communications between that user and a speech-able user or another user with a speech disability.

In Speech-to-Speech the relay agent: 1) Expects to hear someone with distorted speech or a speech synthesizer and is therefore not shocked or confused by them, 2) Uses earphones to eliminate all background noise, 3) Has acute hearing, 4) Can concentrate on understanding the words as the agent has no interest in content or no emotional involvement with the speaker to distract her/him, 5) Can solicit the speech-able user's patience. The speech of the trial participants was usually understandable under these favorable conditions.

The evaluation of the trial showed that: 1) The telecommunications message can be conveyed with a tolerable level of frustration for the users and agent, 2) Speed of communications is increased compared with that experienced in current relay calls initiated by very slow typists.

THE 1996-1997 TRIAL

A second trial ran from June 10, 1996 until December 8, 1997. During most of that trial two outreach consultants with counseling degrees worked full-time on this task for the California Deaf and Disabled Telecommunications Program. We developed a usable outreach model. This process involved identifying the best sources for referrals of Speech-to-Speech Users.

We telephoned a large proportion of California neurologists, physical medicine physicians and otolaryngologists (ENT). Generally, about one in five neurologists has at least one patient with a speech disability. Generally, physicians were reluctant to make referrals until we identified our medical-counseling credentials. We received positive response and cooperation from physical medicine physicians and those speech therapists who work in hospitals.

Because of the psychological resistance of potential users, we often had to telephone them up to ten times before they are willing to initiate a Speech-to-Speech call themselves. Family members and caretakers can require extensive counseling concerning their loss of role and power when people with speech disabilities begin to use the telephone independently.

Outreach was crucial because there were not yet enough Speech-to-Speech users for the CPUC to justify removing Speech-to-Speech from provisional status. With only 150 current users (estimated), effective outreach was necessary to insure that usage grew fast enough to justify the CPUC continuing Speech-to-Speech.

The Permanent Service

The service is a success and is now permanent in twelve states! Consumers like the California service which they demonstrate both by the high call volume and by their comments. Now, an estimated 150-250 users made more than 5,000 calls a month. This is about triple the number of calls being made in June 1996 when the service began. The large majority of consumers say that the CAs understand their speech most of the time and that their calls are successful.

Speech-to-Speech allows many customers to use the telephone independently for the first time! When one customer was asked if she would attempt the same calls on her own without Speech-to-Speech, she replied: "Never in a million years!" Several employers of users say that using Speech-to-Speech has improved on the job communication. One recent college graduate said that she can now apply to law school because Speech-to-Speech is available so she can telephone clients.

Dr. Judy Montgomery, Past National President of the American Speech-Language-Hearing Association said that Speech-to-Speech relieved the able-bodied caller of responsibility for deciphering garbled speech and allowed her to concentrate on the content of the call. An aide in the Governor's Office was impressed with the potential of Speech-to-Speech to increase the employment opportunities of Californians with speech disabilities.


Speech-to-Speech is now a permanent service in California and many other states. The Federal Communication Commission has brought Speech-to-Speech under the purview of the ADA and requires that it be available everywhere in the US by March, 2001.

As a footnote, next to getting married and earning a Ph.D., developing Speech-to-Speech is the most exciting thing I ever did. Can you imagine the joy of helping others overcome what has been your own personal worst frustration? Psychologists will understand when I say that working to provide telephone service to other people with speech disabilities is for me a task at the very top of Maslow's scale of human activity.

Note: Some of this material was published previously in a variety of places.

Bob Segalman, Ph.D., Research Analyst
Program Evaluation and Statistics Section
California Department of Rehabilitation
3330 Tropicana Court
Sacramento, CA 95826
phone 1-800-854-7784 and ask for me at 916-263-8689

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